What the world can learn from South Korea’s coronavirus strategy - South Korea was one of the earliest countries to report a significant Covid-19 outbreak, but since then its number of new cases has dramatically declined. Here's what we can learn from its response

WILL BEDINGFIELD, wired: “Test, test, test,” World Health Organisation director-general Tedros Adhanom Ghebreyesus implored countries fighting the novel coronavirus at a press conference on March 16. “You cannot fight this fire blindfolded.” The UK seems finally to have heeded this advice, announcing plans on March 19 to up test for Covid-19 to 25,000 every day.

As of March 20, the UK had only tested 64,621 people – more than any other European country apart from Italy but still far below the level needed to truly track the extent of the outbreak. But if the UK needs a role model for implementing these tests, it could do worse than look towards South Korea.

Korea’s outbreak began like Italy’s, with a slow drip of cases soon turning into a dramatic escalation. In the months following China's first reports of the virus, the country kept its case numbers low – just thirty infections had been recorded when, on February 18, a woman reported to a hospital in Daegu, the country’s fourth largest city. It became clear that this woman, who has been dubbed “patient 31” and is a member of a quasi-Christian sect – the Shincheonji Church of Jesus – had been ill for some time, and had repeatedly ignored pleas to be tested. (Alarming details have since emerged of her attending church services and a buffet lunch, despite having a high fever.)

The Korea Centers for Disease Control and Prevention would quickly announce that 9,300 people attended the two Shincheonji church services alongside patient 31 and 1,200 were now complaining of flu-like symptoms. Hundreds would test positive in the coming days. During a 10-day period in late February, cases leapt above 5,000.

Yet South Korea, where the outbreak total stands, as of March 19, at 8,652 cases and 94 deaths, now has a case rate in relative decline. Just 93 new cases were reported on March 18 (though numbers rose again on 19, to 152.) During the worst periods of February, Korean officials were recording more than 900 a day.

The backbone of Korea’s success has been mass, indiscriminate testing, followed by rigorous contact tracing and the quarantine of anyone the carrier has come into contact with. As of March 19, the country has conducted more than 307,000 tests, the highest per capita in the world. The UK has conducted 64,600; The US even less that. “You have countries like the US right now, where there's a fairly strict criteria of who can be tested,” says Kee Park, a lecturer on global health at Harvard Medical School. “I know people personally who have symptoms that are highly suspicious, but they don't meet all the criteria and so they're not being tested.”

“[South Korea’s] extensive testing is a very valuable tool to both control the virus and understand and measure the effectiveness of the responses that are taking place,” says Michael Mina, assistant professor at the Center for Communicable Disease Dynamics at Harvard University. “It’s allowed individuals to take matters into their own hands and make social distancing decisions on their own, both to protect those around them and to protect themselves from those who are infected around them.”

To carry out testing at this scale requires extraordinary coordination. The Wall Street Journal reports that the country can test more than 20,000 people a day at 633 testing sites nationwide. A smartphone app provides GPS maps to track the infection’s spread. Medics pitch massive white tents on roadsides, where citizens receive free drive through testing, reducing the need to clean infected hazmat suits. Results are swift, too, coming by text within 24 hours.

The response has melded with Korean technological ingenuity, explains Park.“Koreans are super good at making things convenient for people – we don't have any patience,” he says. “South Korea is one of the most wired countries in the world, where everybody uses cell phones for just about everything, and [the government] was able to use our cell phones to not only track but send warnings, like ‘watch out, there's a Covid-19 patient in your vicinity.’”

Korean healthcare, a highly regulated, efficient single payer system, is also prepared to face epidemics. The country failed to contain the 2015 outbreak of Middle East respiratory syndrome (MERS), recording 186 cases and 38 deaths, more than anywhere outside the Middle East. After the WHO excoriated Korea’s response, the country overhauled their response to respiratory infections, fast-tracking the production of test kits and equipping hospitals with infection control units and negative pressure rooms.

The Korean population, shaken by the incident, are also more likely to wash their hands, stay at home and get tested if requested to. “Testing like this has been very successful with dealing with HIV, for example, to prevent its spread and onward transmission,” says Mina. “There were large campaigns to test people to see if they know their status, and then to act appropriately.”

When China first reported the coronavirus, South Korea’s CDC developed testing kits extremely quickly. “There was a lot of criticism about the way the MERS epidemic was handled,” says Park. “The South Korean government and the Ministry of Health and Social Welfare, they learnt ‘well we don’t want to go through this again’, and so had a plan in place.”

A key part of this testing is to find and isolate asymptomatic carriers, before they spread the infection unwittingly. Though Korea’s death rate, at 0.6 per cent, is likely lower because the outbreak has been restricted to young members of the population, a new study suggests that five in every 10 cases are undetectable.

Knowing who is a carrier reduces the need for more draconian government measures, like lockdowns. “If everybody stays in their room and doesn't go outside at all, which is the Chinese approach, then that also is very effective at cutting down transmissions,” says Martin Hibberd, professor of emerging infectious diseases at the London School of Hygiene and Tropical Medicine. “But in the absence of that type of approach, I think identifying who is positive and making sure those are quarantined is clearly a very effective way.”

So should the UK be replicating this strategy? The government has been vague about the reasons behind our slow rate of testing – on Tuesday and Wednesday, only 6000 tests per day were reported.

WIRED has contacted DHSC for more details about how the government will carry out 25,000 tests, and who will receive them, but did not receive a response by the time of publication. “The government position seems to have changed since Thursday,” says Hibberd. “It seems clear now that the reason there was not more testing done is because of a logistics problem. Places like South Korea managed to do an impressive task of ramping up to a very large scale across the whole country. Clearly, that's not the simplest thing to do, and looks like in the UK, we're still trying to copy that process.”

It may also have been inefficient. “At one point recently about 25,000 tests had been done in the UK to find around 456 cases,” says Julii Brainard, from the University of East Anglia’s Norwich Medical School. “Basically 98 per cent of those with symptoms or contact history didn’t have Covid-19. Testing obviously was expensive, taking time and resources, yet not especially effective in Britain.”

One significant trade off South Korea has had to make, and that the UK may soon grapple with, is the trade-off between public health and civil liberties. Not just the restriction of movement – cancelling schools; home working; ending mass gatherings – but also the erosion of privacy. “I’m biased because I'm a public health practitioner, but you have to allow some loss of personal liberties and rights for the good of the whole population,” says Park. “You can't have social distancing, for example, if 10 per cent of the population says ‘I'm not going to follow that’ – the whole thing falls apart.”

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What’s Behind South Korea’s COVID-19 Exceptionalism?

Seven weeks ago, South Korea and the U.S. had the same number of virus deaths. Today, South Korea has fewer than 300, and the U.S. has more than 70,000.

Derek Thompson, The Atlantic: n february 16, a sunday, a 61-year-old woman with a fever entered the Shincheonji Church of Jesus in Daegu, South Korea. She touched her finger to a digital scanner. She passed through a pair of glass doors and proceeded downstairs, to the prayer hall, where she sat with approximately 1,000 other worshippers in a large windowless room. Hours later, she exited the building and left behind a trail of pathogens that would lead to thousands of infections, triggering one of the largest coronavirus outbreaks in the world.

By the end of February, South Korea had the most COVID-19 patients of any country outside China. New confirmed cases were doubling every few days, and pharmacies were running out of face masks. More than a dozen countries imposed travel restrictions to protect their citizens from the Korean outbreak, including the U.S., which had, at the time, recorded an official COVID-19 death toll low enough to count on one hand.

But just as South Korea appeared to be descending into catastrophe, the country stopped the virus in its tracks. The government demanded that the Shincheonji Church turn over its full membership list, through which the Ministry of Health identified thousands of worshippers. All were ordered to self-isolate. Within days, thousands of people in Daegu were tested for the virus. Individuals with the most serious cases were sent to hospitals, while those with milder cases checked into isolation units at converted corporate training facilities. The government used a combination of interviews and cellphone surveillance to track down the recent contacts of new patients and ordered those contacts to self-isolate as well.

Within a month, the Korean outbreak was effectively contained. In the first two weeks of March, new daily cases fell from 800 to fewer than 100. (This morning, the nation of 51 million reported zero new domestic infections for the third straight day.) On April 15, the country successfully held a national parliamentary election with the highest turnout in three decades, without triggering another wave. South Korea is not unique in its ability to bend the curve of daily cases; New Zealand, Australia, and Norway have done so, as well. But it is perhaps the largest democracy to reduce new daily cases by more than 90 percent from peak, and its density and proximity to China make the achievement particularly noteworthy.

In the time that South Korea righted its course, the United States veered into disaster. In mid-March, the U.S. and South Korea had the same number of coronavirus-caused fatalities—approximately 90. In April, South Korea lost a total of 85 souls to COVID-19, while the U.S. lost 62,000—an average of 85 deaths every hour. That the U.S. population is approximately six times larger than South Korea’s does little to soften the horror of the comparison.

Juxtaposing the South Korean response with the American tragedy, some commentators have chalked up the difference to an ancient culture of docile collectivism and Confucianism across the Pacific. This observation isn’t just racist. It also exoticizes South Korea’s success and makes it seem like the inevitable result of millennia of cultural accretion, rather than something the U.S., or any other country, can learn from right now. The truth is that the Korean government and its citizens did something simple, admirable, and all too rare: They suffered from history, and they learned from it.

South korea’s covid-19 policy was forged in the crucible of previous public-health crises. In 2002, the SARS outbreak killed several hundred people in East Asia. In 2009, the H1N1 influenza, which likely originated in Mexico, spread to more than 1 million people globally and killed several hundred South Koreans. From these epidemics, South Korean public-health officials recognized the necessity of early testing and the importance of isolating new patients to prevent secondary infections.

But 2015’s Middle East Respiratory Syndrome, or MERS, created the playbook that the country has used to break the back of COVID-19.

In May 2015, a 68-year-old man returning to South Korea from a business trip to the Middle East had a fever. After visiting several clinics, he was admitted to a hospital in Seoul with a mysterious case of pneumonia. By the time doctors had diagnosed him with the viral respiratory infection MERS, the disease had spread, through the clinics and hospitals he’d visited, to several dozen patients. One of them, a 35-year-old man, left the hospital where he was infected and went to another medical center. There, he caused another outbreak. Within weeks, the disease was running rampant through the South Korean hospital system.

“MERS was transfixing and frightening to Koreans, because the disease was spreading through crowded hospitals and their waiting rooms,” Scott Snyder, a senior fellow for Korea studies at the Council on Foreign Relations, told me. “People were getting sick, but they were also afraid of going to the hospital for fear that it would make them even more sick.”

The government made several damaging mistakes before arresting the spread of MERS. In the early days of the epidemic, testing kits were unavailable, as was information about the viral spread. When the government refused to announce which hospitals were witnessing outbreaks, citizens and politicians alike slammed it for its lack of transparency.

In response to MERS, South Korea rewrote much of its infectious-disease-prevention legislation. To expedite testing, it gave laboratories the green light to use unapproved diagnostic kits during a public-health emergency. To expand contact tracing, it gave health authorities warrantless access to CCTV footage and the geolocation data from the new patients’ phones. To increase transparency, the new laws required local governments to send prompt alerts, such as emergency texts, to disclose the recent whereabouts of new patients. “The government has failed, and the people have lost their trust,” declared Moon Jae-in, the head of the opposition party during the MERS outbreak. The public approved of both the sentiment and its source. Two years later, Moon was elected president of South Korea.

Today, south korea’s covid-19 response strategy sits atop three pillars: fast and free testing, expansive tracing technology, and mandatory isolation of the most severe cases. Each pillar was shaped by the epidemics that preceded the 2019 novel coronavirus.

Fast Testing

One of the key lessons of MERS was that bending the curve required an accelerated plan for designing, manufacturing, and distributing accurate tests. In the coronavirus pandemic, no large democracy has been better on these counts than South Korea.

Yascha Mounk: No testing, no treatment, no herd immunity, no easy way out

In late January, just one week after the country’s first case was diagnosed, government officials urged medical companies to develop coronavirus test kits and told manufacturers to prepare for mass production. By mid-February—while the U.K. was talking about “herd immunity” and President Donald Trump was predicting that the virus would “miraculously” disappear in weeks—South Korea was churning out thousands of test kits every day. By March 5, South Korea had tested 145,000 people—more than the U.S., the U.K., France, Italy, and Japan combined.

To spare hospitals from being overrun with patients, as they were in 2015, Korean officials opened 600 testing centers and pioneered the use of drive-through testing stations to reduce face-to-face contact indoors. Inspired by drive-through counters at fast-food restaurants, these pop-up centers offered patients 10-minute tests without forcing them to leave their cars.

Expansive High-Tech Tracing

In most countries, contact tracing—or, simply, tracing—refers to the practice of interviewing recent patients to learn where, when, and to whom they might have passed along the disease. South Korea combines that approach with high-tech surveillance made possible by the post-MERS legislation mentioned above.

“The way Seoul does it is, they’ll send out an alert saying that there were X number of new confirmed cases today, if any, and that you can check their routes on the district website,” Yung In Chae, a writer based in Seoul, told me in an email. “On the website, each patient is identified [by] their gender and their age. They also note, with asterisks, whether their houses have been disinfected, whether there were contacts, and whether they were wearing masks the entire time. Lately, most of our cases have been imported, so the routes are pretty boring: People are going from the airport, to quarantine in their house, to their community health center to get tested.”

This level of surveillance might alarm some Americans. But, again, it’s important to consider South Korea’s response in the context of the MERS outbreak. In 2015, the government’s most public failure was its refusal to share any information about the hospitals where sick patients might have visited. In 2020, South Koreans seem mindful of the trade-offs between privacy and public health, and the sources I spoke with welcomed tracing technology. “I’m fine with the amount of information shared,” Yung In Chae said. “I think that we’ve figured out a good balance between guarding privacy and public health.”

The national mapping of citizen activity yields fast results. On a Saturday in April, a 58-year-old man was diagnosed with the coronavirus. Surveillance data showed that he had voted in the election and visited several restaurants in previous days. Within 48 hours, South Korea had identified—and, in some cases, interviewed—more than 1,000 people who had potentially come into contact with him. All of them were instructed to self-isolate, thus cordoning off the virus’s spread. By the end of the month, no new clusters appeared in the Korean infection data.

Zero-Tolerance Isolation

To separate the sick from the healthy—and the somewhat sick from the very sick—South Korea’s patients are divided into several groups. The elderly and those with serious illnesses go straight to hospitals. Moderately sick people are sent to isolation dorms, where they’re monitored. And the asymptomatic “contacts” of recently diagnosed cases are asked to self-quarantine at home and use separate bathrooms, dishes, and towels from their cohabitants. Health-service officials check in twice daily to monitor their symptoms.

International arrivals are also subject to isolation rules. South Korea requires that foreign arrivals self-isolate for two weeks. Koreans arriving from overseas are required to download an app that registers their symptoms in the days after their arrival. By early April, South Korea reported that more than 170,000 inbound travelers had downloaded the app, and nearly 9,000 of them had reported symptoms requiring hospitalization or mandatory quarantine. (Individuals who violate self-isolation rules face steep fines or, for foreigners, immediate deportation.)

Central isolation is not yet a part of most U.S. states’ response to the virus. But it ought to be. One of the hallmarks of the countries that have contained the COVID-19 threat has been the systematic separation of sick people and their contacts from healthy people. Testing and tracing are important, but a virus is indifferent to nasal swabs and Bluetooth-tracing apps. It seeks hosts, and without a national plan to remove sick people from healthy populations, the disease can still spread among families and neighbors.

“Test, trace, and isolate” is the three-legged stool of South Korean public-health policy. But what keeps the stool upright is the shared confidence between the government and the public. “A delicate balance of trust … drives the entire thing,” the writer Yung in Chae told me.

People trust the government in part because it works to keep raw politics out of public health. South Korea’s Ministry of Health has for months held daily briefings to update the public and convey best practices, such as social distancing and hand-washing. “These briefings are held by scientists, not politicians,” Scott Snyder told me. “Imagine having a 10 a.m. and 2 p.m. briefing from the White House, with Dr. [Anthony] Fauci in the morning and Dr. [Deborah] Birx in the afternoon, and no other members of the White House.”

And the government trusts the public to act as a responsible co-partner in public health. Rather than announcing an official lockdown that would fully close restaurants and businesses and force citizens to stay home, the Korean government has opted to keep more of its economy open. “We were never on lockdown, and we’re still not on lockdown,” Paul Choi, a consultant who lives in Seoul, told me. “But citizens have taken it upon ourselves to stay inside. We’re very careful to wash our hands and keep our distance. Almost everybody is wearing masks. If you don’t wear masks, you get looks on the street.”-

Before the crisis, Choi said, he would leave his apartment early, ride a crowded subway, elbow his way through a packed gym to the treadmills, and then go to the office. “Today, the subway is much less crowded, because more people work from home,” he said. “When I arrive at my office building, there are temperature cameras in the lobby. There’s a regular diner that I go to for lunch, and the staff there tell me that their work schedules have been reduced to avoid layoffs. Larger social gatherings, at bars and restaurants, have been paused.”

I asked Choi how the country had come together so quickly to stem the spread of the disease. “It’s about civic memory, not Confucius,” he said. “We remember MERS. We remember other epidemics. We know this is a marathon. But we’re in a better place because the entire society has been in this game, fighting together.”

As he spoke, my mind turned to vaccination. A live vaccine uses a weakened version of a virus to teach the immune system how to respond to the real thing. Long after the vaccine is gone, the body remembers its immuno-playbook and stands prepared to fight a stronger pathogen in the future. South Korea’s national immune system was instructed and strengthened by previous crises. Other epidemics came and went, but they left behind guidance that Koreans recalled and executed when they were suddenly confronted with the plague of the century.

South Korea’s world-class response to COVID-19 is not the product of religion, or cultural destiny, but rather the result of diseases bested and crises weathered. Unlike the biological response to a pathogen, public policy is not an automatic response, but a deliberate one. South Korea chose to learn. The United States entered this pandemic discombobulated, blundering, and hamstrung by our lack of readiness. Neither history nor contagion will wait for us to catch up. That is the bad news. The good news is that history will go on. And we still have time to learn from it.